NCLEX: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

Health Promotion and Maintenance; Nursing Care of the Childbearing Family: THE INTRAPARTUM EXPERIENCE

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

VII. NURSING MANAGEMENT OF THE NEWBORN IMMEDIATELY AFTER BIRTH

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Assessment:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Mucus in nasopharynx, oropharynx.

2. Apgar score: note and record—at 1 and 5 minutes of age (Apgar Score).

a. Score of 7–10: good condition.

b. Score of 4–6: fair condition; assess for CNS depression.

c. Score of 0–3: poor condition; requires immediate intervention. Asphyxia neonatorum—fails to breathe spontaneously within 30–60 seconds after birth; heart rate (HR) <100.

3. Number of vessels in umbilical stump.

4. Passage of meconium stool, urine.

5. General physical appearance/status.

a. Signs of respiratory distress (nasal flaring, grunting, sternal retraction, cyanosis, tachypnea).

b. Skin condition (meconium stained, cyanosis, jaundice, lesions).

c. Cry—presence, pitch, quality.

d. Signs of birth trauma (lacerations, dislocations, fractures).

e. Symmetry (absent parts, extra digits, gross malformations, ears, palm creases, sacral dimples).

f. Molding, caput succedaneum, cephalohematoma.

g. Assess gestational age.

6. Identify high-risk infant.

 

B. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Ineffective airway clearance related to excessive nasopharyngeal mucus.

2. Ineffective breathing pattern related to CNS depression secondary to intrauterine hypoxia narcosis, prematurity, and lack of pulmonary surfactant.

3. Impaired gas exchange related to respiratory distress.

4. Fluid volume deficit related to birth trauma; hemolytic jaundice.

5. Impaired skin integrity related to cord stump.

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

 

6. High risk for injury (biochemical, metabolic) related to impaired thermoregulation.

7. Ineffective thermoregulation related to environmental conditions/prematurity.

C. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Goal: ensure patent airway.

a. Suction mouth first, then nose; when stimulated, sensitive receptors around entrance to nares initiate gasp, causing aspiration of mucus present in mouth.

b. Suction with bulb syringe.

  • If deeper suctioning necessary, use DeLee Mucus Trap attached to suction. Oral use of DeLee is contraindicated due to risk of contact with baby’s secretions (new DeLee now available that has no such risk).
  • Avoid prolonged, vigorous suctioning.

(a) Reduces oxygenation.

(b) May traumatize tissue, cause edema, bleeding, laryngospasm, and cardiac arrhythmia.

c. Assist gravity drainage of fluids. Position: head dependent (Trendelenburg) and side-lying position.

2. Goal: maintain body temperature—to conserve energy, preserve store of brown fat, decrease oxygen needs; prevent acidosis. Prevent chilling:

a. Minimize exposure; dry quickly.

b. Keep warm; apply hat.

c. Take temperature hourly until stable.

3. Goal: identify infant:

a. Apply Identiband.

b. Take infant’s footprints and maternal fingerprints.

4. Goal: prevent eye infection (gonorrheal and chlamydial ophthalmia neonatorum). Within 1 hour of birth, apply antibiotic ointment in each eye.

5. Goal: facilitate prompt identification/vigilance for potential neonatal complications.

a. Record significant data from mother’s chart:

  • History of: pregnancy, diabetes, hypertension, current drug abuse, excessive caffeine, medications, alcohol, malnutrition.
  • Course of labor, evidence of fetal distress, medications received in labor.
  • Birth history of anesthesia.
  • Apgar score; resuscitative efforts.

6. Goal: facilitate prompt identification/intervention in hemolytic problems of the newborn.

a. Collect and send cord blood for appropriate tests:

  • Blood type and Rh factor.
  • Coombs’ test.

b. Give vitamin K to facilitate clotting.

D. Evaluation/outcome criteria: successful transition to extrauterine life.

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Status satisfactory; all assessment findings within normal limits.

2. Responsive in bonding process with parents.

VIII. NURSE-ATTENDED EMERGENCY BIRTH (PRECIPITATE BIRTH)—When woman presents without prenatal care (to emergency department), may represent drug abuse.

IMMINENT BIRTH

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Assessment: identify signs of imminent birth:

1. Strong contractions.

2. Bearing-down efforts.

3. Perineal bulging; crowning.

4. Mother states, “It’s coming.”

B. Analysis/nursing diagnosis:

1. Pain related to:

a. Strong, sustained contractions.

b. Descent of fetal head.

c. Stretching of perineum.

2. Anxiety/fear related to imminent birth.

3. Ineffective individual coping related to circumstances surrounding birth; anxiety, fear for self and infant.

4. Injury (mother) related to lacerations (vaginal, perineal).

5. Fluid volume deficit related to:

a. Lacerations.

b. Uterine atony.

c. Retained placental fragments.

6. Impaired gas exchange (infant) related to intact membranes after birth.

7. Risk for injury (infant) related to:

a. Precipitate birth.

b. Trauma.

c. Hypoxia.

C. Nursing care plan/implementation:

1. Goal: reduce anxiety/fear—reassure mother.

2. Goal: delay birth, as possible.

a. Discourage bearing-down efforts.

b. Encourage panting.

c. Side-lying position to slow descent and allow for more controlled birth.

3. Goal: prevent infection.

a. Provide clean field for birth.

b. Avoid touching birth canal without gloved hands.

c. Support perineum (and advancing head) with sterile (or clean) towel.

4. Goal: prevent, or minimize, infant hypoxia and perineal lacerations.

a. If membranes intact as head emerges, tear at neck to facilitate first breath.

b. Feel for cord around neck (if present, and if possible, slip cord over head; if tight, and sterile equipment at hand, clamp cord in two places, cut between clamps, unwrap cord). If unsterile environment, keep fetus and placenta attached—do not cut cord.

5. Goal: facilitate/assist birth.

a. Hold head in both hands.

b. Apply gentle downward pressure to bring anterior shoulder under pubic symphysis.

c. Gently lift head to ease birth of posterior shoulder.

d. Support infant as body slips free of mother’s body.

6. Goal: facilitate drainage of mucus and fluid → patent airway.

a. Hold infant in head-dependent position.

b. Clear mucus with bulb syringe (if available), or use fingertip, wipe with towel.

7. Goal: prevent placental transfusion—hold infant level with placenta until cord stops pulsating; clamp and cut.

8. Goal: prevent chilling.

a. Wrap infant in towel or other clean material.

b. Place infant on side, head dependent, on mother’s abdomen.

c. Dry head, cover with cap or material.

9. Goal: stimulate respiration. If neonate fails to breathe spontaneously:

a. Maintain body temperature—dry and cover.

b. Clear airway

  • Position: head down.
  • Turn head to side.

c. Stimulate.

  • Rub back gently.
  • Flick soles of feet.

d. If no response to stimulation:

  • Slightly extend neck to “sniffing” position (head tilt–chin lift method).
  • Place mouth over newborn’s nose and mouth and exhale air in cheeks, saying “ho” (prevents excessive pressure).

10. Goal: begin cardiopulmonary resuscitation (CPR) if heart rate <60 beats/min.

a. Place infant on firm, flat surface.

b.With two fingers placed 1/2 to 3/4 of an inch above the xyphoid process, depress 1/3 to 1/2 depth of anterior-posterior chest.

c. Assist ventilation on upstroke of every third compression (3:1 ratio).

d. Go immediately to emergency department.

11. Goal: maintain infant’s body temperature.

a.Wrap placenta with baby, if cord intact.

b. Place infant in mother’s arms.

 PLACENTAL SEPARATION

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Assessment—third stage: identify signs of placental separation.

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

B. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Goal: avoid/minimize potential for complications (everted uterus, tearing of placenta with fragments remaining, separation of cord from placenta).

a. Avoid traction (pulling) on cord.

b. Avoid vigorous fundal massage.

c. Discourage maternal bearing-down efforts unless placenta visible at introitus.

d.With fundus well contracted, and placenta visible at introitus, encourage mother to bear down to expel placenta.

2. Goal: prevent maternal hemorrhage (uterine atony).

a. Encourage breastfeeding, or stimulate nipple.

b. Gently massage fundus, support lower part of uterus, and express clots when uterus is contracted.

c. Encourage voiding if bladder is full.

d. Get to a medical facility.

3. Goal: encourage bonding/stimulate uterine contractions. Encourage breastfeeding.

4. Goal: legal accountability as birth attendant. Record date, time, birth events, maternal and fetal status.

C. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Experiences normal spontaneous birth of viable infant over intact perineum.

2. Uncomplicated fourth stage—status satisfactory for both mother and infant.

3. Expresses satisfaction in management and result.

IX. ALTERATIONS AFFECTING PROTECTIVE FUNCTION

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Induction of labor—deliberate initiation of uterine contractions.

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Indications for:

a. History of rapid or silent labors, precipitate birth.

b.Woman resides some distance from hospital (controversial).

c. Coexisting medical disorders:

  • Uncontrolled diabetes.
  • Progressive preeclampsia.
  • Severe renal disease.
  • Cardiac disease.

d. PROM—spontaneous rupture of membranes before onset of labor and less than 37 weeks from last menstrual period. Hazards:

  • Maternal—intrauterine infection (chorioamnionitis, endometritis).
  • Fetal—sepsis; prolapsed cord.

e. Rh or ABO incompatibility, fetal hemolytic disease.

f. Congenital anomaly (e.g., anencephaly).

g. Post-term pregnancy with nonreactive non-stress test (NST), or oligohydramnios.

h. Intrauterine fetal demise.

2. Criteria for induction:

a. Absence of CPD, malpresentation, or malposition.

b. Engaged vertex of single gestation.

c. Nearing, or at term.

d. Fetal lung maturity.

  • Survival rate—better at 32 weeks or more.
  • Lecithin/sphingomyelin ratio greater than 2:1.
  • Mother who is diabetic—PG is present in amniotic fluid.

e. “Ripe” cervix—softening, partially effaced, or ready for effacement/dilation (if not already present). Note: Intravaginal or paracervical application of prostaglandin gel, or misoprostol may be used to prepare cervix for labor.

3. Methods:

a. Amniotomy—artificial rupture of membranes with fetal head engaged and dilation of cervix.

b. Intravenous oxytocin infusion.

4. Potential complications:

a. Amniotomy—irrevocably committed to birth.

Hazards:

  • Prolapsed cord.
  • Infection.

b. IV oxytocin infusion:

  • Over-stimulation of uterus.
  • Decreased placental perfusion/fetal distress, neonatal jaundice.
  • Precipitate labor and birth.
  • Cervical/perineal lacerations.
  • Uterine rupture.
  • Postpartum hemorrhage.
  • Water intoxication—if large doses given in D/W over prolonged period (anti-diuretic effect increases water reabsorption).
  • Hypertensive crisis.

BEFORE INDUCTION

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

5. Assessmentbefore induction:

a. Estimate of gestation (EDD, fundal height, cervical status).

b. Bishop’s score: evaluation of cervical inducibility.

c. General health status:

  • Weight, vital signs, FHR, edema.
  • Status of membranes.
  • Vaginal bleeding.
  • Coexisting disorders.

d. History of previous labors, if any.

e. Emotional status.

f. Knowledge/understanding of anticipated procedures:

  • Amniotomy (artificial rupture of membranes).
  • Cervical ripening (prostaglandin gel, Cervidil, Cytotec).
  • IV oxytocin infusion.
  • Fetal monitoring

g. Preparation for childbirth (Lamaze method, etc.); coping strategies. Identify support person.

6. Analysis/nursing diagnosis:

a. Knowledge deficit related to process of induction.

b. Anxiety/fear related to need for induction of labor.

c. Ineffective individual coping related to psychological stress.

d. Pain related to uterine contractions.

7. Nursing care plan/implementation:

a. Goal: health teaching.

  • Explain rationale for procedures:

(a) Amniotomy.

(i) Induces labor.
(ii) Relieves uterine over-distention.
(iii) Increases efficiency of contractions, shortening labor.

(b) Oxytocin infusion.

(i) Induces labor.
(ii) Stimulates uterine contractions.

(c) Internal fetal monitor.

(i) Provides continuous assessment of uterine response to oxytocin stimulation.
(ii) Provides continuous assessment of fetal response to physiological stress of labor.

  • Describe procedure—to reduce anxiety and increase cooperation.
  • Explain advantages/disadvantages—to ensure “informed consent.”

b. Goal: emotional support—encourage verbalization of concerns; reassure, as possible.

8. Evaluation/outcome criterion: woman verbalizes understanding of process, rationale, procedures, and alternatives.

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DURING INDUCTION AND LABOR

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

9. Assessmentduring induction and labor:

a. Amniotomy—same as for spontaneous rupture of membranes:

  • Observe fluid—note color, amount.
  • Monitor FHR; assess for fetal distress.
  • Observe for signs of prolapsed cord.
  • Assess fetal activity.

(a) Excessive activity may indicate distress.

(b) Absence of activity may indicate distress or demise.

b. IV oxytocin infusion:

  • Continually assess response to oxytocin stimulation/flow rate; always given by controlled infusion.

(a) Uterine contractions.

(b) Maternal vital signs, FHR.

  • Identify signs of:

(a) Deviation from normal patterns:

(i) Lack of response to increasing flow rate.
(ii) Uterine hyperstimulation (contractions—less than 2 minutes apart).
(iii) Lack of adequate uterine relaxation between contractions.

(b) Side effects of oxytocin: diminished output—potential water intoxication.

(c) Hazards to mother or fetus:

(i) Sustained (over 90-second) or tetanic (strong, spasm-like) contractions—potential abruptio placentae, uterine rupture, fetal hypoxia/anoxia/death.
(ii) Fetal arrhythmias, decelerations.
(iii) Maternal hypertension—potential for hypertensive crisis, cerebral hemorrhage.

10. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

a. Same as for other women in labor.

b. If indications of deviations from normal patterns:

  • Change maternal position.
  • Stop oxytocin infusion, maintain IV with Ringer’s lactate, etc.
  • Begin oxygen per mask; up to 8 to 10 L/min.
  • Notify physician promptly.
  • Check maternal blood pressure and pulse rate.

c. Anticipatory guidance: may or may not have strong contractions soon after induction starts.

11. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

a. Demonstrates response to oxytocin stimulation.

  • Establishes desired contraction pattern, not hyperstimulated.
  • Progresses through labor—within normal limits:

(a) Normotensive.

(b) Voids in adequate amounts.

(c) No evidence of deviation from normal contraction patterns.

b. No evidence of fetal distress.

c. Experiences normal vaginal birth of viable infant.

B. Operative obstetrics—procedures used to prevent trauma/reduce hazard to mother or infant during the birth process.

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Episiotomy—incision of perineum to facilitate infant’s birth.

a. Rationale:

  • Surgical incision reduces possibility of laceration.
  • Protects infant’s head from pressure exerted by resistant perineum.
  • Shortens second stage of labor.

b. Types:

  • Midline—chance of extension into anal sphincter greater than with mediolateral.
  • Mediolateral—healing is more painful than midline.

c. Assessment:

  • REEDA:

(a) Redness

(b) Edema

(c) Ecchymosis

(d) Discharge

(e) Approximation (suture line intact, separated)

  • Healing.
  • Bruised; hematoma.
  • Tenderness; pain. Note: Evaluate complaints of pain carefully. If intense, and unrelieved by usual measures, report promptly. May indicate vulvar, paravaginal, or ischiorectal abscess or hematoma.

d. Analysis/nursing diagnosis:

  • Pain related to labor process.
  • Impaired skin integrity related to surgical incision.
  • Fluid volume deficit related to hematoma.
  • Sexual dysfunction related to discomfort.

e. Nursing care plan/implementation:

  • Goal: prevent/reduce edema, promote comfort and healing.

(a) Place covered ice pack during immediate postpartum. (b) Administer analgesics, topical sprays, ointments, witch hazel pads, hydrocortisone. (c) Encourage use of sitz bath or rubber ring. (d) Encourage Kegel exercises. (e) Do health teaching:

(i) Instruct in tightening gluteal muscles before sitting.
(ii) Instruct to avoid sitting on one hip.

  • Goal: minimize potential for infection.

(a) Teach/provide perineal care during fourth stage of labor.

(b) Health teaching: instruct in self-perineal care after voiding, defecation, and with each pad change.

f. Evaluation/outcome criteria:

  • Woman’s incision heals by primary intention.
  • Woman demonstrates appropriate self-perineal care.
  • Woman evidences no signs of hematoma, infection, or separation of suture line.
  • Woman experiences minimal discomfort.

2. Forceps-assisted birth—use of instruments to assist birth of infant.

a. Indications:

  • Fetal distress.
  • Maternal need:
    (a) Exhaustion.
    (b) Coexisting disease, such as cardiac disorder.
    (c) Poor progress in second stage.
    (d) Persistent fetal occipitotransverse (OT) or occipitoposterior (OP) position.

b. Criteria for forceps application:

  • Engaged fetal head.
  • Ruptured membranes.
  • Full dilation.
  • Absence of CPD.
  • Some anesthesia has been given; usually, episiotomy has been performed.
  • Empty bladder.

c. Types:

  • Low—outlet forceps.
  • Mid—applied after head is engaged (rarely used).
  • Piper forceps—applied to after-coming head in selected breech births (rarely done).

d. Potential complications:

  • Maternal:

(a) Lacerations of birth canal, rectum, bladder.

(b) Uterine rupture/hemorrhage.

  • Neonatal:

(a) Cephalohematoma.

(b) Skull fracture.

(c) Intracranial hemorrhage, brain damage.

(d) Facial paralysis.

(e) Direct tissue trauma (abrasions, ecchymosis).

(f) Umbilical cord compression.

e. Assessment:

  • FHR immediately before—and after—forceps application (forceps blade may compress umbilical cord).
  • Observe mother/newborn for injury or signs of complications.

f. Analysis/nursing diagnosis:

  • Self-esteem disturbance related to inability to give birth without surgical assistance.
  • Anxiety/fear related to infant’s appearance (forceps marks) or awareness of potential complications.

g. Nursing care plan/implementation:

  • Goal: minimize feelings of failure due to inability to give birth “naturally.”

(a) Explain, discuss reasons/indications for forceps-assisted birth.

(b) Emphasize no maternal control over circumstances.

  • Goal: reduce parental anxiety, maternal guilt over infant bruising/forceps marks. Explain condition is temporary and has no lasting effects on child’s appearance.

h. Evaluation/outcome criteria:

  • Woman verbalizes understanding of reasons for forceps-assisted birth.
  • Woman evidences no interruption in bonding with infant.
  • Woman experiences uncomplicated recovery.

3. Vacuum extraction (soft plastic cup with vacuum from a handheld suction pump). Used to assist in rotation or delivery of the fetal head.

a. Risks may include caput succedaneum and cephalohematoma.

b. Causes neonatal jaundice; intraventricular hemorrhage can result in death.

4. Cesarean birth—incision through abdominal wall and uterus to give birth.

a. Indications for elective cesarean birth:

  • Known CPD.
  • Previous uterine surgery (e.g., myomectomy), repeated cesarean births (depends on type of incision done).
  • Active maternal genital herpes type 2 infection; human papillomavirus (HPV).
  • Breech presentation. Note: To reduce infant morbidity/mortality, elective cesarean birth is common method of choice.
  • Neoplasms of cervix, uterus, or birth canal.
  • Maternal diabetes with placental aging; fetal macrosomia (CPD); >4050 gm.

b. Criterion for elective cesarean birth: L/S ratio greater than 2:1—indicates presence of pulmonary surfactant; less risk of respiratory distress syndrome.

c. Indications for emergency cesarean birth:

  • Fetal:

(a) Fetal distress: prolapsed cord, repetitive late decelerations, prolonged bradycardia.
(b) Fetal jeopardy: Rh or ABO incompatibility.
(c) Fetal malposition/malpresentation.

  • Maternal:

(a) Uterine dysfunction; rupture.
(b) Placental disorders:

(i) Placenta previa.
(ii) Abruptio placentae, with Couvelaire uterus.

(c) Severe maternal preeclampsia/eclampsia.
(d) Fetopelvic disproportion.
(e) Sudden maternal death.
(f) Carcinoma.
(g) Failed induction.

d. Types:

  • Low segment—method of choice:

(a) Transverse incision through abdominal wall and lower uterine segment.
(b)Transverse incision through abdominal wall, with vertical incision of lower uterine segment.
(c) Advantages—fewer complications:

(i) Less blood loss.
(ii) More comfortable convalescence.
(iii) Less adhesion formation.
(iv) Lower risk of uterine rupture in subsequent pregnancy/labor and birth.
(v) Cosmetically more acceptable.

  • Classical—vertical incision through abdominal wall and uterus. May be necessary for anterior placenta previa and transverse lie, less than 28 weeks’ prematurity.
  • Porro’s—hysterotomy followed by hysterectomy. Necessary in presence of:

(a) Hemorrhage from uterine atony.
(b) Placenta accreta/percreta.
(c) Large uterine myomas.
(d) Ruptured uterus.
(e) Cancer of uterus or ovary.

e. Assessment:

  • Maternal physical status.

(a) Vital signs.
(b) Labor status, if any.
(c) Contractions (if any).
(d) Membranes (intact; ruptured).
(e) Bleeding.

  • Fetal status.

(a) FHR pattern.
(b) Color and amount of amniotic fluid.
(c) Biophysical profile (BPP), if performed.

  • Maternal emotional status.
  • Understanding of procedure, indications for, implications.
  • Other—as for any abdominal surgery.

f. Analysis/nursing diagnosis:

  • Self-esteem disturbance related to perceived failure to give birth vaginally.
  • Anxiety/fear related to impending surgery and/or reasons for cesarean birth.
  • Ineffective individual coping related to anxiety and fear for self, infant.
  • Fluid volume deficit related to abdominal surgery or reason for cesarean birth.
  • Pain related to abdominal surgery.
  • Constipation related to decreased bowel activity.
  • Altered urinary elimination related to fluid volume deficit.

g. Nursing care plan/implementation:

  • Preoperative:

(a) Goal: safeguard fetal status.

(i) Monitor fetal heart rate continually.
(ii) Notify neonatology and neonatal intensive care unit (NICU) of scheduled surgical birth, if suspect complications.

(b) Goal: health teaching.

(i) Describe, discuss anticipated anesthesia.
(ii) Explain rationale for preoperative antacids to minimize effects of aspiration: cimetidine, Bicitra, histamine blocker to decrease production of gastric acid; Reglan (metoclopramide), to hasten gastric emptying.
(iii) Describe, explain anticipated procedures—abdominal shave, indwelling catheter, intravenous fluids—to woman and support person.

(c) Other—as for any abdominal surgery.
(d) Prepare for cesarean birth.

  • Postoperative:

(a) Same as for other clients having abdominal surgery.
(b) Same as for other women who are postpartum.

h. Evaluation/outcome criteria:

  • Verbalizes understanding of reasons for cesarean birth.
  • Successful birth of viable infant.
  • Evidences no surgical/birth complications.
  • Evidences no interference with bonding.
  • Expresses satisfaction with procedure and result.

5. Trial of labor after cesarean (TOLAC)

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

a. Candidates for TOLAC.

  • Previous low transverse cesarean birth.
  • Fetal head well engaged in pelvis (vertex presentation).
  • Soft, anterior cervix.
  • Preexisting reason for repeat cesarean birth not apparent.

b. Assessment:

  • Monitor FHR carefully during trial of labor.

Monitor contractions carefully for adequate progress of labor.

  • Observe mother for signs of complications/uterine rupture.

c. Analysis/nursing diagnosis:

  • Knowledge deficit related to trial of labor.
  • Fear related to outcome for fetus.
  • Ineffective individual coping related to labor progress and outcome.
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FURTHER READING/STUDY:

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